The effects of interactive and passive distraction on cold pressor pain in preschool-aged children

Effect of interactive vs. passive virtual reality on pain threshold and tolerance

OBJECTIVES

Scientific evidence suggests that virtual reality (VR) could potentially help patients tolerate painful medical procedures and conditions. The aim of this study was to evaluate the efficacy of virtual reality on pain tolerance and threshold.

METHODS

A within-subjects experimental study design was conducted on 53 female students at Qassim University in Saudi Arabia. Each participant completed three rounds of assessment: one baseline (no VR) and two VR immersion (passive and interactive) in random order sequence. During each round, participants submerged their non-dominant hand into an ice bath; pain threshold and tolerance were measured as outcomes and analyzed using repeated measures ANOVA.

RESULTS

Participants had both higher pain threshold and tolerance during interactive and passive VR rounds in comparison to the non-VR baseline assessment (p<0.05). Participants had greater pain tolerance during the interactive VR condition compared to the passive VR condition (p<0.001).

CONCLUSIONS

VR experiences increase pain threshold and tolerance with minimal side effects, and the larger effects were demonstrated using interactive games. Interactive VR gaming should be considered and tested as a treatment for pain.

Am I being watched? The role of researcher presence on toddlers' behaviour during 'everyday' pain experiences: a pilot study

Objective: Paediatric research on 'everyday' pain experiences is sparse, stemming from a lack of appropriate methodologies. We explored the feasibility of two methodologies for conducting naturalistic observations of 'everyday' pains within family's homes, against an established methodology for day-care observations. Design: Within family homes, video-cameras recorded a typical morning or afternoon (maximum three hours), either with, or without researcher presence. To compare feasibility, children in day-care were observed by researchers for three hours without video-recording. Outcome measures: logistics of observation, child pain behaviours, caregiver responses to child pain. Results: Thirteen children (M_age = 45.4 months) were recorded at home, experiencing 14 pain events. Researcher presence increased child distress intensity, but reduced the number of pain events compared to sessions without a researcher. Thirty-two children (M_age = 48.4 months) were observed in day-care, experiencing 44 pain events. Children experiencing pain events in day-care exhibited decreased distress and lower personal control than those observed at home. Across all conditions, caregivers engaged mostly in physical comfort. Researcher estimates of child pain were highest if scored while present in the home. Conclusions: Observing everyday pain events within the child's natural environment is feasible and may provide insight into the social context of childhood pain experiences.

Application of animated cartoons in reducing the pain of dressing changes in children with burn injuries

BACKGROUND

Nonpharmacological management remains one of the central pain interventional therapies in the burn unit. VR and other distraction treatments for adults have achieved great advantages in pain relief.

METHODS

A within-subject study was conducted to evaluate 54 participants aged from 3 to 7. In the control group, a standard analgesic, ibuprofen, was used over the period of dressing change, whereas animated cartoons were played simultaneously in the intervention-group condition. We adopted the Wong-Baker faces pain rating scale, COMFORT scale, FLACC scale and POCIS to assess the pain rating 5 min before, during and 5 min after dressing changes, respectively.

RESULTS

Compared with the control group, FLACC scale and POCIS scores in the intervention group were not significantly different (P>0.05) throughout the observation period; outcomes measured using the Wong-Baker faces pain rating scale and COMFORT scale 5 min before and during dressing changes were also not different between the groups (P>0.05). Nevertheless, 5 min after that period, subjects in the intervention group had reduced pain behavior according to scores on the Wong-Baker faces pain rating scale (control-group scores: 7.231±0.403; intervention-group scores: 6.026±0.501, P<0.05) and COMFORT scale (control-group scores: 21.602±1.316; intervention-group scores: 19.040±1.204, P<0.05).

CONCLUSION

This study supports that watching animated cartoons appears to be a practical way to ease the pain behavior of children in the burn unit after replacing wound dressings, although its effectiveness remains insufficient before and during the dressing change procedure.

SIGNIFICANCE

Conducting a thorough study and exploring the efficacy of animated cartoons in reducing the pain of dressing changes for pediatric patients may surely result in practical value, especially in developing countries.

Testing the Possibility of Model-based Pavlovian Control of Attention to Threat

Signals for reward or punishment attract attention preferentially, a principle termed value-modulated attention capture (VMAC). The mechanisms that govern the allocation of attention can be described with a terminology that is more often applied to the control of overt behaviors, namely, the distinction between instrumental and Pavlovian control, and between model-free and model-based control. Although instrumental control of VMAC can be either model-free or model-based, it is not known whether Pavlovian control of VMAC can be model-based. To decide whether this is possible, we measured steady-state visual evoked potentials (SSVEPs) while 20 healthy adults took part in a novel task. During the learning stage, participants underwent aversive threat conditioning with two conditioned stimuli (CSs): one that predicted pain (CS+) and one that predicted safety (CS-). Instructions given before the test stage allowed participants to infer whether novel, ambiguous CSs (new_CS+/new_CS-) were threatening or safe. Correct inference required combining stored internal representations and new propositional information, the hallmark of model-based control. SSVEP amplitudes quantified the amount of attention allocated to novel CSs on their very first presentation, before they were ever reinforced. We found that SSVEPs were higher for new_CS+ than new_CS-. This result is potentially indicative of model-based Pavlovian control of VMAC, but additional controls are necessary to verify this conclusively. This result underlines the potential transformative role of information and inference in emotion regulation.

Pediatric Pain Management

Nearly 20 years ago, standards were established for hospitals to assess and treat pain in all patients. Research continues to demonstrate evolving trends in the measurement and effective treatment of pain in children. Behavioral research demonstrating long-lasting effects of inadequate pain control during childhood supports the concepts of early and adequate pain control for children suffering from painful conditions in the acute care setting. The authors discuss pain concepts, highlighting factors specific to the emergency department, and include a review of evidence for pharmacologic and nonpharmacologic treatments.

Ambient versus traditional environment in pediatric emergency department

OBJECTIVE

We sought to examine the effect of exposure to an ambient environment in a pediatric emergency department. We hypothesized that passive distraction from ambient lighting in an emergency department would lead to reduction in patient pain and anxiety and increased caregiver satisfaction with services.

BACKGROUND

Passive distraction has been associated with lower anxiety and pain in patients and affects perception of wait time. A pediatric ED was designed that optimized passive distraction techniques using colorful ambient lighting.

METHODS

Participants were nonrandomly assigned to either an ambient ED environment or a traditional ED environment. Entry and exit questionnaires assessed caregiver expectations and experiences. Pain ratings were obtained with age-appropriate scales, and wait times were recorded.

RESULTS

A total of 70 participants were assessed across conditions, that is, 40 in the ambient ED group and 30 in the traditional ED group. Caregivers in the traditional ED group expected a longer wait, had higher anxiety pretreatment, and felt more scared than those in the ambient ED group. Caregivers in the ambient ED group felt more included in the care of their child and rated quality of care higher than caregivers in the traditional ED group. Pain ratings and administrations of pain medication were lower in the ambient ED group.

CONCLUSIONS

Mean scores for the ambient ED group were in the expected direction on several items measuring satisfaction with ED experiences. Results were suggestive of less stress in caregivers, less pain in patients, and higher satisfaction levels in the ambient ED group.

Hand-held computers can help to distract children undergoing painful venipuncture procedures

AIM

Needle-related procedures can be painful for children, and distraction provides ideal pain relief in blood-drawing centres. This study assessed the effectiveness of playing a computer game during venipuncture, compared with low-tech distraction by a nurse.

METHODS

We conducted this prospective, randomised controlled trial at the blood-drawing centre of a tertiary-level children's hospital in Italy. Half of the 200 children played Angry Birds on a hand-held computer while the other half were distracted by a second, specifically trained nurse who sang to them, read a book, blew bubbles or played with puppets. Pain was measured using a faces pain scale for children aged 4-7 years and a numeric scale for children aged 8-13 years.

RESULTS

The 200 children had a median age of eight years. Children reported significant pain in 16 cases (16%) in the hand-held computer distraction group and in 15 cases (15%) in the nurse-led low-tech distraction group (p = 0.85). The procedural success rate at the first attempt was not different in the two groups.

CONCLUSION

Playing a game on a hand-held computer meant that only one in six children reported pain during venipuncture, but it was not superior to being distracted by nurses.

The Assessment and Non-Pharmacologic Treatment of Procedural Pain From Infancy to School Age Through a Developmental Lens: A Synthesis of Evidence With Recommendations

The 2011 IOM report stated that pain management in children is often lacking especially during routine medical procedures. The purpose of this review is to bring a developmental lens to the challenges in assessment and non-pharmacologic treatment of pain in young children.

METHOD

A synthesis of the findings from an electronic search of PubMed and the university library using the keywords pain, assessment, treatment, alternative, complementary, integrative, infant, toddler, preschool, young, pediatric, and child was completed. A targeted search identified additional sources for best evidence.

RESULTS

Assessment of developmental cues is essential. For example, crying, facial expression, and body posture are behaviors in infancy that indicate pain: however in toddlers these same behaviors are not necessarily indicative of pain. Preschoolers need observation scales in combination with self-report while for older children self-report is the gold standard. Pain management in infants includes swaddling and sucking. However for toddlers, preschoolers and older children, increasingly sophisticated distraction techniques such as easily implemented non-pharmacologic pain management strategies include reading stories, watching cartoons, or listening to music.

DISCUSSION

A developmental approach to assessing and treating pain is critical. Swaddling, picture books, or blowing bubbles are easy and effective when used at the appropriate developmental stage and relieve both physical and emotional pain. Untreated pain in infants and young children may lead to increased pain perception and chronic pain in adolescents and adults. Continued research in the non-pharmacological treatment of pain is an important part of the national agenda.

Effect of Playing Interactive Computer Game on Distress of Insulin Injection Among Type 1 Diabetic Children

BACKGROUND

Diabetic children and their families experience high level stress because of daily insulin injection.

OBJECTIVES

This study was conducted to investigate the impact of an interactive computer game on behavioral distress due to insulin injection among diabetic children.

PATIENTS AND METHODS

In this clinical trial, thirty children (3-12 years) with type 1 diabetes who needed daily insulin injection were recruited and allocated randomly into two groups. Children in intervention groups received an interactive computer game and asked to play at home for a week. No special intervention was done for control group. The behavioral distress of groups was assessed before, during and after the intervention by Observational Scale of Behavioral Distress-Revised (OSBD-R).

RESULTS

Repeated measure ANOVA test showed no significantly difference of OSBD-R over time for control group (P = 0.08), but this changes is signification in the study group (P = 0.001). Comparison mean score of distress were significantly different between two groups (P = 0.03).

CONCLUSIONS

According to the findings, playing interactive computer game can decrease behavioral distress induced by insulin injection in type 1 diabetic children. It seems this game can be beneficial to be used alongside other interventions.

Tablet-based Interactive Distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: a noninferiority randomized trial

INTRODUCTION

Perioperative anxiety is a common and undesirable outcome in pediatric surgical patients. The use of interactive tools to minimize perioperative anxiety is vastly understudied. The main objective of the current investigation was to compare the effects of a tablet-based interactive distraction (TBID) tool to oral midazolam on perioperative anxiety. We hypothesized that the TBID tool was not inferior to midazolam to reduce perioperative anxiety.

METHODS

108 children, ages 1-11 years, presenting for outpatient surgical procedures were prospectively randomized to oral midazolam (0.5 mg·kg(-1); 20 mg max) or TBID. The primary outcome was the change in anxiety level from baseline to parental separation and anesthetic induction. Other data collected included emergence delirium, parental satisfaction, time-to-PACU discharge, and posthospitalization behavior.

RESULTS

The mean difference (95% CI) in the increase of anxiety at parental separation between the TBID and the midazolam group was -9 (-2.6 to -16.4), P = 0.006, demonstrating superiority to midazolam group (one-sided P = 0.003). For children 2-11 years, the mean difference (95% CI) in anxiety at induction was significant between the TBID and midazolam groups, -14.0 (-6.1 to -22.0), P < 0.001. The median (IQR) time-to-PACU discharge was 111 (75-197) min in the midazolam group and 87 (55-137) min in the TBID group, P = 0.03. Decreased emergence delirium and increased parental satisfaction were also observed in the TBID group.

CONCLUSIONS

A TBID tool reduces perioperative anxiety, emergence delirium, and time-to-discharge and increases parental satisfaction when compared to midazolam in pediatric patients undergoing ambulatory surgery.

Relevance of Water Temperature, Apparatus, and Age to Children's Pain during the Cold Pressor Task

BACKGROUND

Effective use of experimental pain in research depends on a thorough understanding of factors influencing their use. Although studies using the cold pressor task (CPT) have critically advanced our knowledge of pain mechanisms, assessment, and management in adults and children, the impact of identified methodological variability in its use is not known (ie, water temperature and apparatus); furthermore, whether methodological variations differentially impact children across development.

METHODS

Pain outcomes were examined in 113 healthy children from three age groups (8- to 9-, 10- to 11-, and 12- to 14-year-olds) who completed three CPTs at different water temperatures (5, 7, 10°C) in counterbalanced order. Children were randomly assigned to one of two apparatus (ice- vs. electric-cooled) for all CPTs. Children's hand was warmed to its baseline temperature between CPTs.

RESULTS

Colder water (2 to 3°C decreases) was associated with significantly higher pain intensity and unpleasantness, and lower pain tolerance and threshold. Older children (12 to 14 years) reported significantly worse pain intensity and unpleasantness as compared to 8- to 9-year-olds, likely due to longer pain tolerance. Pain outcomes in 10- to 11-year-olds fell between the other age groups, with significant differences for pain unpleasantness and pain tolerance (at 10°C). Higher pain-related fear and pain unpleasantness occurred with the electric-cooled apparatus. Girls had higher pain tolerance and threshold at all temperatures.

CONCLUSIONS

These results provide critically important information about water temperature, apparatus, and child age on CPT pain responding. It informs design of future CPT studies and directs consideration of methodological variability and child age when interpreting study findings.

Nurses' Perceptions of the Practice of Restricting a Child for a Clinical Procedure

Restricting a child for a clinical procedure has been linked to negative physical and psychological sequelae. The practice of restriction remains an implicit and unquestioned aspect of care for children during a clinical procedure. In this study we aimed to describe the practice of restricting a child's movement for a clinical procedure by conducting focus groups with children's nurses. Data were analyzed using a thematic network analysis framework. The findings show that nurses are likely to restrict children based on particular characteristics of the child; for example, the child's age. The findings indicate that there is no consistent approach to the practice of restricting a child for a clinical procedure, suggesting tension between nurses and other health care professionals, and nurses and parents, about this practice. The findings suggest the need for wider exploration of the practice of restriction at the organizational level and a need for children's nurses to feel more empowered to act as advocates for those in their care.

An exploration of the practice of restricting a child's movement in hospital: a factorial survey

AIMS AND OBJECTIVES

To identify the reported predictors of the practice of restricting a child for a clinical procedure in hospital.

BACKGROUND

Previous work in this area is dominated by discussion papers and suggestions for addressing the issue of restriction. This is the first study to explore reported predictors of this practice with a view to implementing change based on research findings.

DESIGN

A factorial survey was developed, which incorporated the use of vignettes with various scenarios. The factorial design enabled exploration of the interaction of multiple factors on the practice of restriction.

METHODS

One hundred and sixty-six nurses caring for children were each sent 10 vignettes and asked to rate their likelihood to restrict a child based on the vignettes. A total of 105 nurses responded to the survey, representing a response rate of 63%. Hierarchical linear regression was used to identify reported predictors of restriction.

RESULTS

Nurses were more likely to restrict a child if they had prior instruction on safe holding, if there was no play therapist available, if the nurse was a registered general nurse with no other registration qualification, if the child required cannulation or if the child was less than five years of age.

CONCLUSION

This study identified predictors of restriction from the perspective of practicing nurses; the evidence needs to be used in developing clinical guidelines and in multidisciplinary education.

RELEVANCE TO CLINICAL PRACTICE

There is a need to move from any presumption of restriction towards more critical consideration of the individual requirements of the child. There is a need to increase the numbers of nurses receiving specialist training on the care of a child in hospital. The importance of a well-resourced play therapy service is supported, and there is a need for multidisciplinary work to explore alternatives to restriction.

A practical guide and perspectives on the use of experimental pain modalities with children and adolescents

Use of experimental pain is vital for addressing research questions that would otherwise be impossible to examine in the real world. Experimental induction of pain in children is highly scrutinized given the potential for harm and lack of direct benefit to a vulnerable population. However, its use has critically advanced our understanding of the mechanisms, assessment and treatment of pain in both healthy and chronically ill children. This article introduces various experimental pain modalities, including the cold pressor task, the water load symptom provocation test, thermal pain, pressure pain and conditioned pain modulation, and discusses their application for use with children and adolescents. It addresses practical implementation and ethical issues, as well as the advantages and disadvantages offered by each task. The incredible potential for future research is discussed given the array of experimental pain modalities now available to pediatric researchers.

Responses to tonic heat pain in the ongoing EEG under conditions of controlled attention

To confirm the existence of an ongoing electroencephalogram (EEG) pattern that is truly suggestive of pain, tonic heat pain was induced by small heat pulses at 1 °C above the pain threshold and compared to slightly less intense tonic non-painful heat pulses at 1 °C below the pain threshold. Twenty healthy subjects rated the sensation intensity during thermal stimulation. Possible confounding effects of attention were thoroughly controlled for by testing in four conditions: (1) focus of attention directed ipsilateral or (2) contralateral to the side of the stimulation, (3) control without a side preference, and (4) no control of attention at all. EEG was recorded via eight leads according to the 10/20 convention. Absolute power was computed for the frequency bands delta (0.5-4 Hz), theta (4-8 Hz), alpha1 (8-11 Hz), alpha2 (11-14 Hz), beta1 (14-25 Hz), and beta2 (25-35 Hz). Ratings were clearly distinct between the heat and pain conditions and suggestive for heat and pain sensations. Manipulation of attention proved to be successful by producing effects on the ratings and on the EEG activity (with lower ratings and lower EEG activity (theta, beta1, 2) over central areas for side-focused attention). During pain stimulation, lower central alpha1 and alpha2 activity and higher right-parietal and right-occipital delta power were observed compared to heat stimulation. This EEG pattern was not influenced by the manipulation of attention. Since the two types of stimuli (pain, heat) were subjectively felt differently although stimulation intensities were nearby, we conclude that this EEG pattern is clearly suggestive of pain.

Audiovisual distraction reduces pain perception during aural microsuction

Introduction

Aural microsuction is a common ear, nose and throat procedure used in the outpatient setting. Some patients, however, find it difficult to tolerate owing to discomfort, pain or noise. This study evaluated the effect of audiovisual distraction on patients’ pain perception and overall satisfaction.

Methods

A prospective study was conducted for patients attending our aural care clinic requiring aural toileting of bilateral mastoid cavities over a three-month period. All microsuction was performed by a single clinical nurse specialist. Any patients with active infection were excluded. For each patient, during microsuction of one ear, they watched the procedure on a television screen while for the other ear they did not view the procedure. All patients received the same real time explanations during microsuction of both ears. After the procedure, each patient completed a visual analogue scale (VAS) to rate the pain they experienced for each ear, with and without access to the television screen. They also documented their preference and reasons why.

Results

A total of 37 patients were included in the study. The mean pain score for patients viewing the procedure was 2.43 compared with a mean of 3.48 for patients with no television view. This difference in patients’ pain perception was statistically lower in the group who observed the procedure on the television (p=0.003), consistent with the majority of patients reporting a preference to viewing their procedure (65%).

Conclusions

Audiovisual distraction significantly lowered patients’ VAS pain scores during aural microsuction. This simple intervention can therefore reduce patients’ perceived pain and help improve acceptance of this procedure.

Effect of distraction on children's pain during intravenous catheter insertion

PURPOSE

This study examined the effect of pressing a soft ball during intravenous catheter insertion (IVCI) on the intensity of pain in children ages 4-6 years.

DESIGN AND METHODS

In this quasi-experimental study, children in the intervention group were asked to press a soft ball with the opposite hand during IVCI and to immediately mark the Wong-Baker FACES Pain Rating Scale.

RESULTS

There was a significant difference in the intensity of pain between the control group (n = 30) and the intervention group (n = 30; p =.012).

PRACTICE IMPLICATIONS

Pressing a soft ball during IVCI may be an easily accessed, inexpensive, and effective technique to control or reduce pain in young children.

Case study: videogame distraction reduces behavioral distress in a preschool-aged child undergoing repeated burn dressing changes: a single-subject design

OBJECTIVE

This single-subject design study evaluated the feasibility and efficacy of passive and interactive videogame distraction on behavioral distress for a preschool-aged child receiving repeated burn dressing changes.

METHOD

A 4-year-old girl underwent 3 baseline and 10 videogame distraction sessions (5 passive and 5 interactive) using a restricted alternating treatments design. Observed behavioral distress was coded, and parents and nurses rated the child's distress and cooperative behavior.

RESULTS

Relative to baseline, behavioral distress decreased and cooperative behavior increased immediately after the onset of videogame distraction. Single Case Randomization Tests revealed significantly lower behavioral distress and greater cooperation during interactive videogame distraction relative to passive videogame distraction.

CONCLUSIONS

Interactive videogame distraction appears to be a feasible and effective pain management strategy for a preschool-aged child undergoing repeated painful medical procedures.